International Journal of Environmental Research and Public Health Article Multiple Gestations and Assisted Reproductive Technologies: Qualitative Study of the Discourse of Health Professionals in Spain Estefanía Jurado-García 1,*, Alicia Botello-Hermosa 2, Francisco Javier Fernández-Carrasco 3,4 , Juan Gómez-Salgado 5,6 , Nazaret Navas-Rojano 7 and Rosa Casado-Mejía 2 1 Department of Nursing, Escuela Universitaria de Osuna, University of Seville, 41640 Sevilla, Spain 2 Department of Nursing, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Sevilla, Spain; [email protected] (A.B.-H.); [email protected] (R.C.-M.) 3 Department of Gynaecology and Obstetrics, Punta de Europa Hospital, 11207 Cádiz, Spain; [email protected] 4 Department of Nursing and Physiotherapy, Faculty of Nursing, University of Cadiz, 11009 Cádiz, Spain 5 Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva, 21007 Huelva, Spain; [email protected] 6 Safety and Health Postgraduate Programme, Espíritu Santo University, Guayaquil 092301, Ecuador 7 EIS Methods, Empresa de Base Tecnológica (Spin Off), University of Huelva, 21007 Huelva, Spain; [email protected] * Correspondence: [email protected]; Tel.: +34-955820289 Citation: Jurado-García, E.; Botello- Abstract: Multiple gestations have become an increasing phenomenon that has impacted public Hermosa, A.; Fernández-Carrasco, F.J.; health globally, largely due to the application of assisted reproductive technologies. The objective of Gómez-Salgado, J.; Navas-Rojano, N.; this work was to find out the discourse that the health professionals involved in its follow-up have Casado-Mejía, R. Multiple Gestations in our context. For this, a qualitative methodology was chosen, with semi-structured interviews and Assisted Reproductive Technologies: recorded in audio, prior authorisation, and transcribed verbatim. It was based on a script designed for Qualitative Study of the Discourse of this purpose, with the following analysis categories: the current trend of multiple gestations, impact, Int. J. Health Professionals in Spain. and follow-up. The content analysis was based on the experiences, knowledge, and perceptions of Environ. Res. Public Health 2021, 18, the professionals interviewed. Professionals stated that the current socioeconomic and legal context 6031. https://doi.org/10.3390/ijerph hinders a single embryo transfer policy that decreases multiple gestation rates. They emphasised the 18116031 importance of the psychic impact of such gestations on the couple, on the mother in particular, as Academic Editor: Domingo well as the economic effect on families, health, and society in general. They expressed the need to Palacios-Ceña create specific protocols to assist these gestations. Midwives, in particular, demanded that the health administration recognise and support the differentiated care they perform with this type of gestation. Received: 28 April 2021 Work on specific models is needed to adequately size the impact of multiple gestations, as well as to Accepted: 31 May 2021 generate social health policies that lead to co-responsible reconciliation measures that favour women Published: 3 June 2021 having one pregnancy at a time. Publisher’s Note: MDPI stays neutral Keywords: multiple pregnancy; assisted reproductive technologies (ART); embryo transfer; advanced with regard to jurisdictional claims in maternal age; health system; maternal psychosocial consequences; parenting; perinatal outcomes; published maps and institutional affil- maternal and perinatal morbidity iations. 1. Introduction Copyright: © 2021 by the authors. In the last fifty years, the incidence of multiple gestations has increased, acquiring Licensee MDPI, Basel, Switzerland. epidemic dimensions, mainly due to delayed procreation and assisted reproductive tech- This article is an open access article nologies (ART). They have gone from representing 2% of births to 30–35% after the use of distributed under the terms and ART [1,2]. conditions of the Creative Commons In this regard, it should be noted that much effort has been made to identify a correct Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ algorithm that considers women’s age and ovarian reserve markers as a tool to optimise the 4.0/). initial dose of recombinant follicle stimulating hormone (rFSH) in intrauterine insemination Int. J. Environ. Res. Public Health 2021, 18, 6031. https://doi.org/10.3390/ijerph18116031 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021, 18, 6031 2 of 15 cycles. However, according to the current available evidence, applying this algorithm with respect to women with polycystic ovary syndrome, especially those with elevated anti- Mullerian hormone, does not seem appropriate [3]. Likewise, the current trend is to perform assisted reproduction treatments associated with ovarian stimulation, but in the case of obese women, these require significantly higher amounts of gonadotropins to achieve the success rates of in vitro fertilisation, similar to those of women with normal weight [4]. Multiple gestations deserve special attention for their disproportionate contribution to maternal and perinatal morbidity, which has a special impact on public health [5]. They imply increased risks of maternal adverse outcomes such as hypertensive pregnancy states, gestational diabetes, bleeding, and postpartum depression (40% more likely), among others. They also involve foetal and neonatal risks such as higher rates of prematurity (50% of births occur before 37 weeks) or perinatal mortality and longer-term neurological developmental disorders (the risk of cerebral palsy is four times higher than in a single gestation) [6,7]. In addition, there are complications typical of twin pregnancy, i.e., growth discordance, intra-uterus foetal death of one of the twins, and twin-to-twin transfusion syndrome [8]. In gestations based on ART, the risk of adverse maternal and neonatal outcomes is further accentuated not only by the higher incidence of multiple pregnancy, the most com- mon undesirable side effect, but also by the manipulation involved in these processes [9]. This has led to the introduction of elective policies for the transfer of individual embryos and declarations of consensus at the international level [10]. The impact of multiple gestations is not only on maternal (physical and emotional) [11] and neonatal health, but also on the health system itself (greater clinical and economic burden), families, and society in general [12]. In Europe, this impact differs among coun- tries, and the number of foetuses in multiple gestation is one of the indicators of the European Perinatal Health Report (Euro-Peristat) programme to measure perinatal health in Europe [2]. This study was raised with the aim of understanding the experience and perception that the involved specialists have through their discourse, hoping to contribute to improve the integral attention to multiple gestations. 2. Materials and Methods 2.1. Study Design This was a qualitative study within the hermeneutic phenomenological perspective, with the aim of knowing and understanding the discourses of Andalusian health profes- sionals involved in the monitoring of multiple gestations. 2.2. Participants The sampling was intentional, starting from two key informant professionals who facilitated the selection of other participants, resulting in a snowball sampling technique. In total, eight professionals directly involved in the monitoring of multiple gestations in the city of Seville participated: 4 gynaecologists working in Assisted Reproductive Units (responsible for 30% of multiple gestations), and 4 primary care (PC) midwives, for their linkage to women throughout the pregnancy and postpartum process. The eight planned interviews were carried out until the saturation level was reached. The targeting criteria were sex and professional category, which originated four profiles, resulting in two interviews per profile. In addition, service time, age, and scope of work were included as attributes that would make it easier to obtain greater discursive power (Table1). Int. J. Environ. Res. Public Health 2021, 18, 6031 3 of 15 Table 1. Profiles of interviewees. Professionals Time of Service Sex Occupation Age (years) Place of Work P 1 15 years Female Midwife 58 PC P 2 30 years Male Midwife 55 PC P 3 20 years Female Midwife 62 PC P 4 30 years Female Midwife 57 PC P 5 12 years Male Gynaecologist 62 Public ART Unit P 6 7 years Female Gynaecologist 47 Public ART Unit P 7 3 years Female Gynaecologist 32 Private ART Unit P 8 24 years Male Gynaecologist 53 Private ART Unit ART, assisted reproductive technologies; PC, primary care. 2.3. Data Collection The fieldwork was carried out in the capital of the province of Seville, between January and February 2018. Semi-structured interviews were conducted. An ad hoc script (Supplementary Materials S1 and S2) was used from the main study dimensions: • Current trend of multiple gestations (embryo transfer policies). • Impact and consequences on the family, society, and the health system. • Monitoring of multiple gestations. • Demands on health administration (emerging category). It was the same script in the two groups, but some different questions were introduced to suit the idiosyncrasy of the assistance given by each group. The affected dimensions were Current Trend of Multiple Gestations with the question: “How do you address the issue of selective reduction?”